Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

Notification Issued Date: N/A

This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 07/01/2020.

The following CPT codes have been

deleted

from this policy:

0124U, 0125U, 0126U, 0127U, 0128U.

The following CPT codes have been

added

to this policy:

0172U, 0173U, 0174U, 0175U, 0176U, 0177U, 0178U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0202U, 0223U, 0224U, 87426, 77063

The following CPT codes have been

revised

in this policy:

0165U

Policy Attachment

Attachment to Policy #

MA00.010as

Attachment:

Policy #:

MA00.010as

Description:

Physical Medicine & Rehabilitation Network Rules and Limited Circumstances

Title:

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

PHYSICAL MEDICINE & REHABILITATION NETWORK RULES AND LIMITED CIRCUMSTANCES

NETWORK RULES PROCEDURE CODE LIST

Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
G0515	01-01-2018	01-01-2020
G0281	04-01-2003
G0283	01-01-2003
S8950	01-01-2000
S9056	01-01-2000
S9090	01-01-2000
S9476	10-01-2003
97001	01-01-1998	12-31-2016
97002	01-01-1998	12-31-2016
97003	01-01-1998	12-31-2016
97004	01-01-1998	12-31-2016
97005	01-01-2002	12-31-2016
97006	01-01-2002	12-31-2016
97010	01-01-1984
97012	01-01-1984
97014	01-01-1983
97016	01-01-1984
97018	01-01-1984
97022	01-01-1984
97024	01-01-1983
97026	01-01-1984
97028	01-01-1984
97032	01-01-1995
97033	01-01-1995
97034	01-01-1995
97035	01-01-1995
97036	01-01-1995
97039	01-01-1984
97110	01-01-1984
97112	01-01-1984
97113	01-01-1995
97116	01-01-1984
97124	01-01-1984
97127	01-01-2018	01-01-2020
97129	01-01-2020
97130	01-01-2020
97139	01-01-1984
97140	01-01-1999
97150	01-01-1995
97161	01-01-2017
97162	01-01-2017
97163	01-01-2017
97164	01-01-2017
97165	01-01-2017
97166	01-01-2017
97167	01-01-2017
97168	01-01-2017
97169	01-01-2017
97170	01-01-2017
97171	01-01-2017
97172	01-01-2017
97530	01-01-1985
97532	01-01-2001	12-31-2017
97533	01-01-2001
97535	01-01-1996
97537	01-01-1996
97542	01-01-1996
97545	01-01-1993
97546	01-01-1993
97610	01-01-2014	09-25-2023
97750	01-01-1995
97755	01-01-2004
97760	01-01-2006
97761	01-01-2006
97762	01-01-2006	12-31-2017
97763	01-01-2018
97799	01-01-1984

LIMITED CIRCUMSTANCES PROCEDURE CODE LIST

CHIROPRACTORS (All Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
G0515	01-01-2018	01-01-2020
G0283	01-01-2003
S8950	01-01-2000
S9056	01-01-2000
S9090	01-01-2000
97010	01-01-1984
97012	01-01-1984
97014	01-01-1983
97016	01-01-1984
97018	01-01-1984
97022	01-01-1984
97024	01-01-1983
97026	01-01-1984
97028	01-01-1984
97032	01-01-1995
97033	01-01-1995
97034	01-01-1995
97035	01-01-1995
97036	01-01-1995
97039	01-01-1984
97110	01-01-1984
97112	01-01-1984
97113	01-01-1995
97116	01-01-1984
97124	01-01-1984
97127	01-01-2018	01-01-2020
97129	01-01-2020
97130	01-01-2020
97139	01-01-1984
97140	01-01-1999
97150	01-01-1995
97530	01-01-1985
97532	01-01-2001	12-31-2017
97533	01-01-2001
97535	01-01-1996
97537	01-01-1996
97542	01-01-1996
97545	01-01-1993
97546	01-01-1993
97750	01-01-1995
97799	01-01-1984

OCCUPATIONAL THERAPIST (All Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
G0515	01-01-2018	01-01-2020
G0281	04-01-2003
G0283	01-01-2003
S8950	01-01-2000
S9476	10-01-2003
97001	01-01-1998	12-31-2016
97002	01-01-1998	12-31-2016
97003	01-01-1998	12-31-2016
97004	01-01-1998	12-31-2016
97010	01-01-1984
97012	01-01-1984
97014	01-01-1983
97016	01-01-1984
97018	01-01-1984
97022	01-01-1984
97024	01-01-1983
97026	01-01-1984
97028	01-01-1984
97032	01-01-1995
97033	01-01-1995
97034	01-01-1995
97035	01-01-1995
97036	01-01-1995
97039	01-01-1984
97110	01-01-1984
97112	01-01-1984
97113	01-01-1995
97116	01-01-1984
97124	01-01-1984
97127	01-01-2018	01-01-2020
97129	01-01-2020
97130	01-01-2020
97139	01-01-1984
97140	01-01-1999
97150	01-01-1995
97161	01-01-2017
97162	01-01-2017
97163	01-01-2017
97164	01-01-2017
97165	01-01-2017
97166	01-01-2017
97167	01-01-2017
97168	01-01-2017
97530	01-01-1985
97532	01-01-2001	12-31-2017
97533	01-01-2001
97535	01-01-1996
97537	01-01-1996
97542	01-01-1996
97545	01-01-1993
97546	01-01-1993
97750	01-01-1995
97755	01-01-2004
97760	01-01-2006
97761	01-01-2006
97762	01-01-2006	12-31-2017
97763	01-01-2018
97799	01-01-1984

OPTOMETRIST FOR LOW VISION SERVICES (Office & Outpatient Hospital Places of Service)
Procedure Code	ICD-10 Codes	Date Code Added to the Policy	Date Code Removed from the Policy
97165	H53.411, H53.412, H53.413, H53.419, H53.421, H53.422, H53.423, H53.429, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.40, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.50, H54.511A, H54.512A, H54.52A1, H54.52A2, H54.60, H54.61, H54.62, H54.7, H54.8	01-01-2017
97166	H53.411, H53.412, H53.413, H53.419, H53.421, H53.422, H53.423, H53.429, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.40, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.50, H54.511A, H54.512A, H54.52A1, H54.52A2, H54.60, H54.61, H54.62, H54.7, H54.8	01-01-2017
97167	H53.411, H53.412, H53.413, H53.419, H53.421, H53.422, H53.423, H53.429, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.40, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.50, H54.511A, H54.512A, H54.52A1, H54.52A2, H54.60, H54.61, H54.62, H54.7, H54.8	01-01-2017
97168	H53.411, H53.412, H53.413, H53.419, H53.421, H53.422, H53.423, H53.429, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.40, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.50, H54.511A, H54.512A, H54.52A1, H54.52A2, H54.60, H54.61, H54.62, H54.7, H54.8	01-01-2017
97535	H53.411, H53.412, H53.413, H53.419, H53.421, H53.422, H53.423, H53.429, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.40, H54.413A, H54.414A, H54.415A, H54.42A3, H54.42A4, H54.42A5, H54.50, H54.511A, H54.512A, H54.52A1, H54.52A2, H54.60, H54.61, H54.62, H54.7, H54.8	01-01-2017

PHYSIATRIST (Office & Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
97110	07/01/2009
97140	07/01/2009
97530	07/01/2009

SPEECH THERAPIST SPECIALIST (Office & Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
G0515	01-01-2018	01-01-2020
97532	01-01-2001	12-31-2017

SPORTS MEDICINE, PEDIATRIC SPORTS MEDICINE & ORTHOPEDIC SPORTS MEDICINE SPECIALIST (Office & Outpatient Hospital Places of Service)
Procedure Code	Date Code Added to the Policy	Date Code Removed from the Policy
97760	07-01-2011

Version Effective Date:

01/01/2025

Version Issued Date:

01/31/2025

Version Reissued Date:

N/A